for Health Care Providers
Integrated Mental Health Care
In many ways, Veterans with HIV infection in VA care represent the future wave of the HIV epidemic in the United States. Compared with the overall HIV-infected population in the United States, Veterans with HIV in VA care are older, more likely to be members of minority groups, and more likely to have a history of substance use. Thus, it is not surprising that they are experiencing an increasing burden of medical and psychiatric comorbid disease. HIV infection has become a complex, chronic disease in which any given problem likely has multiple etiologies. Although this disease is substantially improved by antiretroviral treatment, there are many unaddressed barriers that interfere with initiation of treatment and retention in care. As individuals with HIV infection age, organ injury associated with HIV infection, aging-related comorbid illness, and substance use disorders likely will lead to even more mortality. It is of utmost importance to prioritize and coordinate screening and treatment for important comorbid conditions while maintaining excellence in the care of HIV-infected individuals.
HIV Care Continuum
The HIV care continuum--sometimes referred to as the HIV treatment cascade--is a model used by Federal, state and local agencies to identify issues and opportunities related to improving the delivery of services to people living with HIV across the entire continuum of care. The cascade of HIV care in the United States also has become a focus for interventions aimed at improving the success of HIV treatment (Mangal, Rimland, and Marconi, 2014).
By closely examining the proportion of people living with HIV engaged in each of the five separate stages of the HIV care continuum (Diagnosed, Linked to Care, Retained in Care, Prescribed ART, and Virally Suppressed; see figure below), policymakers and service providers are able to pinpoint where gaps may exist in connecting people living with HIV to sustained, quality care, and to implement system improvements and service enhancements that better support individuals as they move from one stage in the continuum to the next. Knowing where the drop-offs are most pronounced, and for what populations, is vital to knowing how, where, and when to intervene to break the cycle of HIV transmission in the United States.
Figure. HIV Care Continuum
Integrated HIV Care
"Integrated health care," often referred to as interdisciplinary health care, is characterized by a high degree of collaboration and communication among health professionals. What makes integrated health care unique is information sharing among team members related to patient care and the establishment of comprehensive treatment plans to address patients' biological, psychological, and social needs. The interdisciplinary health care team includes a diverse group of members (e.g., physicians, psychologists, social workers, and occupational and physical therapists), depending on the needs of the patient.
Addressing the high prevalence of mental health and substance use disorders (MH/SUD) in Veterans with HIV by increasing the availability of services for such disorders is critically important for successful treatment. Mental health providers in particular can add the following services to an integrated care team:
- Cognitive, capacity, diagnostic, and personality assessments that differentiate normal processes from pathologic states, side effects of medications, adjustment reactions, or combinations of these problems
- Behavioral health assessment and treatment that provide individuals with the self-management skills necessary to effectively manage their chronic conditions
- Diagnosis and treatment of mental and behavioral health problems (e.g., depression, suicide risk, anxiety disorders, addiction, and insomnia)
- Consultation and recommendations to family members, significant others, and other health care providers
Ongoing substance use and active psychiatric disorders are common barriers to HIV treatment among Veterans. These comorbidities affect access to diagnosis, linkage to and retention in care, disease progression, and adherence to antiretroviral treatment.
Given the high prevalence of MH/SUD in Veterans with HIV, increasing the availability of services to address this need is of critical importance in their successful treatment as research shows that integrated mental health care can increase HIV treatment adherence and improve overall health outcomes.
Integrating psychological services into HIV clinical care settings can take many forms. Ojikutu et al. (2014) have emphasized the following aspects for successful models of integrated HIV care:
- Patient centered with integrated or co-located services
- Diverse teams of clinical and nonclinical providers
- A site culture that promotes a stigma-reducing environment
- Availability of comprehensive medical, behavioral health, and psychosocial services
- Effective communication strategies
- Focus on quality
Bonner et al. (2012) propose three models for treatment of patients with chronic hepatitis C virus (HCV) infection, which also can be applied to patients with HIV and HIV/HCV coinfection. They encourage clinics to select the model best suited to local resources and expertise. Some of the advantages of each of these models of care are outlined in the following table.
|Convenience for staff||✓|
|Convenience for patients||✓|
|Most streamlined and efficient||✓|
|Maximizes access to MH/SUD services||✓|
|Strong and ongoing relationship with MH/SUD providers and clinics||✓||✓||✓|
|Providers use outpatient consultation||✓||✓|
|Staffed by nonphysician providers with training in MH/SUD care||✓|
|Brief screening and intervention||✓||✓|
|Assistance in case management||✓||✓|
Across all models of integrated care, a specialty staff is critical for improving treatment outcomes, retention in care, and quality of life for patients. Social work and case management staff are vital to facilitating communication among providers, monitoring treatment outcomes, recognizing concerns that may not present during clinic visits, and connecting Veterans to important resources necessary for continued engagement in care as well as overall health outcomes. Liaison with mental health and substance use staff is also crucial, as primary care is responsible for many patients with comorbid disorders who may not have been diagnosed or treated for MH/SUD.
Integrated care models also utilize Tele-Mental Health services to facilitate access to and delivery of MH/SUD services, especially with regard Veterans who face significant barriers to accessing care. Increased use of telehealth could significantly increase Veterans' access to mental health services by addressing critical barriers to care such as stigma, distance from care providers, and disability. More information is available at: http://www.va.gov/health/newsfeatures/20120813a.asp
General Clinician Tools
Serving Veterans: A Resource Guide
SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)
Clinician Tools for Addressing Substance Use
Reducing Alcohol Use
Treating PTSD in the Context of Complex Medical Issues
Health Psychology/Behavioral Medicine
Bonner JE, Barritt AS 4th, Fried MW, et al. Time to rethink antiviral treatment for hepatitis c in patients. Dig Dis Sci. 2012 Jun;57(6):1469-74.
Fix GM, Asch SM, Saifu HN, et al. Delivering PACT-principled care: are specialty care patients being left behind? J Gen Intern Med. 2014 Jul;29 Suppl 2:S695-702.
Hoang T, Goetz MB, Yano EM, et al. The impact of integrated HIV care on patient health outcomes. Med Care. 2009 May;47(5):560-7.
Mangal JP, Rimland D, Marconi VC. The continuum of HIV care in a Veterans' Affairs Clinic. AIDS Res Hum Retroviruses. 2014 May;30(5):409-15.
Ojikutu B, Holman J, Kunches L, et al. Interdisciplinary HIV care in a changing healthcare environment in the USA. AIDS Care. 2014;26(6):731-5.
Willenbring ML. Integrating care for patients with infectious, psychiatric, and substance use disorders: concepts and approaches. AIDS. 2005 Oct;19 Suppl 3:S227-37.
Zaller N, Gillani FS, Rich JD. A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness. AIDS Care. 2007 Oct;19(9):1128-33.